One Health responses to prevent the occurrence of rabies due to attacks by a rabid stray dog

Abstract Background The number of human rabies cases caused by pet dogs in Guangzhou has been decreasing after years of comprehensive interventions. Consequently, attacks by stray dogs become a major issue in rabies control. Objectives To share our experience of successfully dealing with rabies to provide some inspiration for prevention and control in countries and regions affected by it. Methods A multidisciplinary One Health response was initiated to control this outbreak. Rabies virus was detected by PCR in the brain tissue of the associated stray dog. The sequences were aligned with reference sequences downloaded from GenBank using ClustalX. The maximum likelihood method implemented in MEGA 5.0 software package was used in a phylogenetic analysis of the aligned sequences. Results Twelve patients with exposure to the stray dog were identified in the field investigation. Rabies vaccines and immunoglobulin were administered to all patients within 48 h. After 1 year of follow‐up, no exposed patients showed symptoms. Maximum likelihood analysis of the nucleotide sequences obtained from the PCR products indicated that the rabies virus in the dog was closely related to isolates from neighbouring provinces of Guangdong as well as those from surrounding countries of China. Conclusions Multidisciplinary One Health intervention is effective not only in the control of rabies but also in rapid emergency responses to attacks by rabid stray dogs.

F I G U R E 1 Location of Huashan town and the timeline of stray dog attacks the mortality rate is 100% (Fooks et al., 2014). Tens of thousands of cases of human rabies are reported every year worldwide, most of which occur in developing countries in Asia and Africa (Chen et al., 2017;Qi et al., 2018). In developing countries mammals that transmit rabies virus primarily include dogs, cats and wild animals, and domestic dogs are the main source of infection (Hueffer & Murphy, 2018;LeRoux et al., 2018). In developed countries where dog rabies has been under control, wild animals are the main sources of infection (Brunker & Mollentze, 2018;Chen et al., 2018;Gilbert et al., 2018).
Guangzhou, China, was once a city with a high prevalence of rabies.
Before the 1990s, dozens of cases were reported each year (Wei et al., 2019). After years of effective management and continuous improvement of the monitoring system as parts of a multidisciplinary control strategy, the number of cases in Guangzhou has dramatically decreased since the 1990s. Like most countries or regions with a high incidence of rabies, domestic dog management is the focus of rabies epidemic control in Guangzhou. Although effective registration and immunisation have been established for pet dogs, the threat from stray dogs is not actively addressed. Rapid response to emergencies caused by stray dogs is a top priority before a management policy for stray dogs has been established.
In July 2017, a rabies outpatient human clinic in Huadu District, Guangzhou reported attacks by a suspected stray dog. We analysed the successful emergency responses by a multidisciplinary team. They can potentially serve as a reference for regions with similar cases to achieve the World Health Organization's goal of eliminating human rabies by 2030 (Minghui et al., 2018;Mohammadi, 2016).

Research site
Huashan Town is in the Huadu District of Guangzhou City (Figure 1

Rabies monitoring management system
After years of exploration, Guangzhou has established a rabies surveillance management system at the Guangzhou Center for Disease Control and Prevention (CDC) with multidisciplinary collaboration from other agencies and partners (Wei et al., 2019). Hospitals at all levels and rabies outpatient clinics are responsible for monitoring, searching and follow-up of exposed cases; public security is responsi-

Data sources and case management
As required by the rabies surveillance system, after the emergency, the local government immediately searched for cases exposed to stray dogs in rabies clinics throughout the district (scratched or bitten by stray dogs in Huashan Town during 18-20 July 2017), compared the characteristics of the dogs and time and location of the attack, and determined the number of exposed cases. Twelve exposed cases, two staff members who euthanised stray dogs, and two sample collectors

Detection method
The sera of the exposed cases were analysed using the virus fluorescent antibody virus neutralisation method (FAVN). The N and G genes of rabies virus were amplified by reverse-transcription PCR of RNA extracted from the brain tissues of the stray dog (Feng et al., 2016), with products being sequenced.
The sequences were aligned with reference sequences downloaded from GenBank using ClustalX. The maximum likelihood method implemented in MEGA 5.0 software package was used in a phylogenetic analysis of the aligned sequences. The nucleotide sequences generated from the study were deposited in GenBank under accession numbers MK124757 and MK124758.

Event
In the morning of 20 July 2017, five people bitten by the same suspected rabid dog visited the rabies outpatient clinic of Huashan Hospital. After receiving the report, the Guangzhou CDC launched a joint prevention-and-control action, with the participation of the district CDC, Huashan Town Government, public security, animal husbandry bureau, and other departments.

F I G U R E 2 Positive for rabies virus in the stray dog brain tissue by fluorescent antibody test
In the Huashan district, each rabies outpatient clinic searched for exposed cases bitten by a suspected rabid dog with the same characteristics. The local public security department checked surveillance monitors and searched for the rabid dog and exposed cases. The animal husbandry, agriculture, and forestry departments searched stray dogs in the relevant areas. Pet dogs in this region (a 2.5 km radius of the tracks by the rabid dog) were immunised immunisation. Rabies immunoglobulin and vaccine were administered to all exposed cases, and their rabies neutralising antibody levels assessed. Propaganda on rabies prevention was distributed throughout the entire district, and the public was educated about how to respond to bitten or scratched by animals, including advice on visiting rabies outpatient clinics after potential exposure.
The investigation identified the rabid dog as a stray dog. In the afternoon of 18 July, the first exposed case was attacked, followed by 6 people who were consecutively bitten by the same dog. In the morning of 19 July, another 5 people were attacked. On 20 July, the rabid dog was captured and euthanised ( Figure 1), with brain tissue samples being collected. The results obtained in the afternoon of 21 July indicated that dog was positive (the FITC conjugate is Fujiribio, USA) for rabies virus (Figure 2).

General information on the exposed patients
A total of 12 exposed patients were identified (Table 1), including 3 males and 9 females, ranging in age from 7 to 82 years. Eleven patients were bitten on lower limbs, and 5 people had 3 wounds. The level of TA B L E 1 Information on the exposed cases neutralising antibodies in all exposed patients reached the effective level (>0.5 IU/ml) after 5 doses of the vaccine (Liaoning Chengda Biological Products Co., Ltd.) and active immunotherapy (human rabies immune globulin, 20 IU/kg). During 1 year of follow-up observations, no exposed patients showed symptoms.

Homology analysis of rabies viral G and N gene
The G and N gene sequences of the rabies virus obtained from the rabid dog in Guangdong were compared with those from rabies virus in adjacent provinces and neighbouring countries of China. The phylogenetic tree constructed with the maximum likelihood method showed that the Guangzhou rabies virus strain was located on the same branch as the strains of the neighbouring provinces. In addition, it was closely related to the strains from neighbouring countries (Figure 3a and b).

Critical elements for successful handling of rabies emergencies
The monitoring network of rabies outpatient clinics as the sentinel has played an important role in the identification of this public health emergency. When abnormally exposed patients (bitten or scratched by animals) present to the hospitals, they are required by the network policy to receive close attention, with the intention to identify the causes. Furthermore, the cases should be properly handled and treated to prevent the occurrence of serious public health incidents.
The rabies surveillance and management system involves multiple public health and safety sectors and agencies and is based on the One Health strategy. The previous human-oriented prevention and control strategy has been transformed into a human-and animal-specific pre- In many countries with rabies epidemics, stray dogs are a major public health hazard. Several countries, including India, have implemented the Animal Birth Control (ABC) program, which has achieved good outcomes by vaccinating and sterilising stray dogs to control their numbers and rabies (Totton et al., 2011). Research from Sri Lanka shows that the ABC project is far from sufficient to eliminate threats. According to the density, population structure, and living range of stray dogs and pet dogs in different human environments, government departments should work with veterinarians to develop better strategies (Hou et al., 2012). Countries such as Japan, Thailand and the Philip-pines have introduced regulations to eliminate stray dogs and register, manage and strengthen the immunisation of pet dogs, Guangzhou has established several regulations on pet dogs, but control strategy for stray dogs is still being studied.

The importance of PEP (post-exposure prophylaxis)
Rabies is a zoonotic disease that can be prevented but not cured.
Vaccination and immunoglobulin administration are the only effective post-exposure measures to prevent rabies. Most national strategies for the prevention and control of human and animal rabies are based on active vaccination, including large-scale immunisation against domestic animals, mainly dogs, and wild animals such as foxes and raccoons, in addition to the post-exposure immunisation of humans. Therefore, the supply of high-quality human and animal rabies vaccine, economical and convenient PEP treatment after exposure, and high public awareness of rabies prevention are the first critical steps to eliminate rabies.

Rabies control in the era of globalisation
Results of the phylogenetic analysis indicate that rabies virus strains in Guangzhou are closely related to the strains in neighbouring provinces and countries, highlighting the difficulty of rabies elimination in the era of globalisation (Chen et al., 2017;Lankau et al., 2012). In areas where canine rabies virus has been eliminated, globalisation may lead to rabies viruses being imported and the re-emergence in domestic animals, with serious consequences. To prevent major rabies events caused by globalisation, international collaborations by public health, animal health, tourism, and custom inspection and quarantine departments are needed. They should work together using the One Health strategy in preventing and controlling rabies virus exports and imports (Fitzpatrick et al., 2016;Perez de Diego et al., 2015;Rock et al., 2017;Tan et al., 2017).

CONCLUSION
In an area where human rabies has not been eliminated, the rapid and effective management of attacks by rabid stray dog requires coordinated collaborations of public health, safety and agricultural agencies and local governments. The One Health strategy is effective in both rabies control and prevention and management of postexposure rabies emergencies. Today, with increased globalisation, we should strive to share successful experiences and seek international cooperation to eliminate human rabies.

ACKNOWLEDGEMENTS
Thanks to the staff of Huadu District Center for disease control and prevention, the health system staff of Huashan town and others who helped with this work. This work was supported by the Science and

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.

ETHICAL STATEMENT
This study was approved by the Ethics Committee of Guangzhou Center for Disease Control and Prevention (GZCDC).